HYDROTHERMAL ABLATION IN RECURRENT OR CHRONIC OLECRANON BURSITIS: A PROSPECTIVE STUDY.

BACKGROUND: Olecranon bursitis can be difficult to treat, resulting in persistent or recurrent symptoms. Bursectomy is a frequently applied treatment option for refractory cases but has high complication rates. This is the first in-vivo study to investigate the safety and efficacy of hydrothermal ablation, a new treatment modality for recurrent or chronic olecranon bursitis that aims to cause thermal obliteration of the bursal lining by irrigation with heated saline. METHODS: First, a pilot animal trial was set up to determine a safe irrigation temperature window. Second, in a human trial the bursae of patients with chronic, recurrent or refractory olecranon bursitis were irrigated with a 3 mL/s flow of physiological saline for a duration of 180 seconds at temperatures between 50 and 52 °C. Patients were followed up for 6 months, allowing for assessment of the surgical site to screen for adverse events, volumetric ultrasound assessment of the bursae, and collection of QuickDASH, Patient Global Impression and Clinical Global impression scores, as well as data on return to activities or work. RESULTS: 24 elbows were prospectively included and underwent a full cycle of hydrothermal ablation. The mean age was 58.4 years (range 40.5 - 81.5), including 20 male and 4 female patients. None had clinical signs of septic bursitis. Bursal fluid cultures were positive in only one case. The average preoperative bursal volume was 11.18 cc (range 4.13-30.75). 18 out of 24 elbows (75%) were successfully treated, showing a complete remission of symptoms or decided improvement within 6 weeks and without any signs of recurrence during the entire follow-up period of 6 months. The average reduction of ultrasound-measured bursal volume was 91.9% in the group of patients that responded to treatment. In patients without recurrence the mean QuickDASH-scores before and after treatment were 13.6 (range 0-50) and 3.1 (range 0-27.5) respectively, showing a statistically significant improvement. All patients were able to fully return to work within 6 weeks after the index procedure. No serious adverse events were encountered. Moderate local adverse events were found in 2 patients. Increasing temperatures of irrigation did not result in a higher treatment efficacy. CONCLUSION: Hydrothermal ablation at temperatures between 50 and 52 degrees is a safe treatment option for recurrent or chronic olecranon bursitis with less complications than open bursectomy and a comparable efficacy.

Fracture of the proximal humerus with disruption of the tendon of the pectoralis major.

Combined pectoralis major disruption and proximal humeral fractures are uncommon. A simple radiologic diagnostic tool which consists of the measurement of the displacement from the humeral shaft to the lateral side of the humeral head (lateral to the outer proximal cortex) can help to diagnose this combined lesion.

Subscapularis release in shoulder replacement determines structural muscular changes.

BACKGROUND: Osteotomy of the lesser tuberosity in shoulder arthroplasty allows bony healing of the subscapularis tendon but does not prevent fatty degeneration in its muscle. Occurrence or increase in fatty degeneration may depend on the surgical technique. QUESTIONS/PURPOSES: We (1) assessed fatty degeneration in the subscapularis muscle and its cross-sectional area after a C-block osteotomy of the lesser tuberosity with minimal mobilization of the subscapularis muscle, and (2) determined whether this technique had any adverse effect on function, fatty degeneration, and cross-sectional area of the subscapularis muscle. METHODS: We retrospectively examined 36 patients with shoulder replacements who had C-block osteotomies. Constant-Murley scores and clinical signs of subscapularis insufficiency were recorded. We radiographically assessed prosthetic placement. On CT scans, lesser tuberosity healing, fatty degeneration, and cross-sectional area of the subscapularis muscle were determined. The minimum followup was 13 months (mean, 18 months; range, 13-33 months). RESULTS: The mean absolute Constant-Murley score was 71.2. Two patients had weakness of the subscapularis muscle without loss of active motion. All tuberosities healed anatomically. A normal glenohumeral relationship was found in all cases. Fatty degeneration was Grade 0 in 44%, Grade 1 in 39%, Grade 2 in 14%, and Grade 3 in 3%. The subscapularis muscular cross-sectional area decreased from 16.7 cm(2) preoperatively to 14.5 cm(2) postoperatively (13%). CONCLUSIONS: The C-block osteotomy with minimal dissection of the subscapularis is associated with a low incidence of fatty degeneration in the subscapularis muscle after shoulder arthroplasty although the muscular cross-sectional area of the subscapularis decreased. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Three-dimensional analysis of the orientation and the inclination of the rotator cuff footprint.

HYPOTHESIS: The tuberosities of the proximal humerus relate geometrically to the humeral head in an anteroposterior symmetry. MATERIAL AND METHODS: Twenty-eight cadaveric shoulders were scanned with computed tomography and reconstructed digitally in 3 dimensions. On both tuberosities, 5 facets were identified. An orthogonal planar system using the center of the humeral head as its origin was created to calculate the coordinates of the centre of each facet. The angular position of the center of each facet was measured with reference to the sagittal plane. The inclination of each facet was measured to the axial plane. RESULTS: The presence of 5 distinct facets with a different inclination was confirmed (lesser tuberosity: inferior facet: 77.8° [sd 7.8°]; superior facet: 50.3° [sd 9.3°] - greater tuberosity: superior facet: 20.4° (sd 5.6°); middle facet: 48.6° (sd 5.2°); inferior facet: 92.7° [sd 7.7°]). The angular position of the centers of the facets was less variable (lesser tuberosity: inferior facet: 22.6° [sd 4.3°]; superior facet: 39.2° [sd 4.4°] - greater tuberosity: superior facet: 89.9° [sd 5.9°]; middle facet: 131.6° [sd 6.1°]; inferior facet: 155.1° [sd 6.8°]). CONCLUSION: Our study contributes to the knowledge of the anatomy of the proximal humerus, more specifically of the position of the rotator cuff insertion in relation to the humeral head. These insights are useful in the development of shoulder trauma prostheses.

Extraarticular variants of the long head of the biceps brachii: a reminder of embryology.

Developmental anomalies of the long head of the biceps tendon are rare and have been described in the literature mainly dealing with anatomy and embryology. Because most basic embryologic research on this topic was conducted before 1966, a literature search was performed from archived anatomy textbooks and manuscript references. These data were compared with the scarce case descriptions of developmental anomalies of the long head of the biceps tendon. An additional case illustration from our own experience was provided. From the literature, it appears that during the embryologic phase of development, a staged migration of the long head of the biceps tendon occurs from a position between the fibrous capsule and synovial layer to an intraarticular position. Recent anatomic and arthroscopic case reports have shown that interruption of this migration can occur in any of these stages. Given the recent increase in arthroscopic shoulder surgery, anomalies of the long head of the biceps tendon will be encountered more frequently. Knowledge of their existence and origin can help in evaluating unexpected anatomic variations or the absence of the biceps tendon in preoperative medical imaging or during an arthroscopic procedure.

Arthroscopic rotator cuff repair with double-row fixation.

BACKGROUND: The treatment of rotator cuff tears has evolved from open surgical repairs to complete arthroscopic repairs over the past two decades. In this study, we reviewed the results of arthroscopic rotator cuff repairs with the so-called double-row, or footprint, reconstruction technique. METHODS: Between 1998 and 2002, 264 patients underwent an arthroscopic rotator cuff repair with double-row fixation. The average age at the time of the operation was fifty-nine years. Two hundred and thirty-eight patients (242 shoulders) were available for follow-up; 210 were evaluated with a full clinical examination and thirty-two, with a questionnaire only. Preoperative and postoperative examinations consisted of determination of a Constant score and a visual analogue score for pain as well as a full physical examination of the shoulder. Ultrasonography was done at a minimum of twelve months postoperatively to assess the integrity of the cuff. RESULTS: The average score for pain improved from 7.4 points (range, 3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points) postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. The average increase in the Constant score after the operation was 25.4 points (range, 0 to 57 points). Ultrasonography demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47% (fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two) of the forty-one with a repair of a large tear, 93% (113) of the 121 with a repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a small tear. Strength and active elevation increased significantly more in the group with an intact repair at the time of follow-up than in the group with a failed repair; however, there was no difference in the pain scores. CONCLUSIONS: Arthroscopic rotator cuff repair with double-row fixation can achieve a high percentage of excellent subjective and objective results. Integrity of the repair can be expected in the majority of shoulders treated for a large, medium, or small tear, and the strength and range of motion provided by an intact repair are significantly better than those following a failed repair. LEVEL OF EVIDENCE: Therapeutic Level IV.

A new prosthetic design for proximal humeral fractures: reconstructing the glenohumeral unit.

A new shoulder prosthesis design for proximal humeral fractures has been developed. The rim of the articular component of this prosthesis has several holes to which the bone-tendon junction of the rotator cuff is fixed, to allow an anatomic reconstruction of the glenohumeral unit. The strength of the tuberosity fixation to this prosthesis is investigated in a cadaveric study. Artificial 4-part fractures were created in 18 human, fresh-frozen, paired shoulder joints with intact rotator cuffs. Two methods of tuberosity fixation were used in a matched-pair fashion. In group I the tuberosities were sutured to the rim of the prosthetic head, and in group II the tuberosities were circumferentially tension band-wired. Strength testing was performed on a material-testing machine, and displacement was recorded with an opto-electronic device. Both fixation methods proved to be equally reliable in the forces exerted during activities of daily living without significant displacement of the fracture fragments.

Arthroscopic release of adhesive capsulitis.

Twenty-five patients with primary adhesive capsulitis underwent an arthroscopic release of the capsule of the shoulder joint. They were reviewed after a mean of 14.8 months (range, 3-40 months). Night pain and awakening were a feature in all 25 patients preoperatively but were only found in 3 postoperatively. There was marked improvement in pain from a preoperative visual analog scale score of 3.1 to a postoperative visual analog scale score of 12.6 on a scale of 15. Passive movement of the joint improved significantly, with mean passive elevation changing from 73.7 degrees preoperatively to 163 degrees postoperatively, mean passive external rotation changing from 10.6 degrees preoperatively to 46.8 degrees postoperatively, and passive internal rotation improving by a mean of 9 levels. The mean preoperative Constant score of 25.3 improved to 75.5 postoperatively, and the Constant score adjusted for age and gender averaged 91%. All patients completed the Short Form-36 questionnaire at their review, revealing a norm-based physical summary score of 48.7, falling within 1 SD of a normal population sample. This arthroscopic surgical technique is derived from the open surgical release. It is founded upon an understanding of the pathology of this condition. It appears to yield rapid relief of pain and dramatic improvement in movement and function in this painful and otherwise protracted condition.

Glenohumeral relationship in the transverse plane of the body.

Reconstruction of a normal glenohumeral relationship is desirable for a successful arthroplasty. Double-contrast computed tomography was performed on 49 healthy shoulders in young volunteers. For creation of a uniform spatial reference system, the subjects were positioned in a thoracobrachial orthosis with the arm adducted in the coronal plane and the forearm flexed in the sagittal plane, and they were examined in dorsal recumbency. The classical anatomic angles were measured, and the anatomic axes were determined and quantified as angles to the coronal plane. When the axis of the glenoid was correlated to the axis of the humeral head, a mean of 8.5 degrees divergence in a clear Gaussian distribution was found. This contrasts with the variability of the version of the humeral head and of the glenoid and offers a useful guideline in difficult prosthetic surgery of the shoulder in which normal anatomic landmarks are lost because of arthritic or traumatic deformity.